CAQH CORE Payment & Remittance Operating Rules

Section 4.4 of the CAQH CORE 370 Rule identifies several cross-industry needs identified by CORE Participants during development of the Phase III CAQH CORE EFT & ERA Operating Rules. NACHA – The Electronic Payments Association is the organization responsible for the development and maintenance of the NACHA Operating Rules which govern the ACH Network and maintains the CCD+ standard format. To address the identified cross-industry needs, in November 2012, NACHA adopted a new healthcare payments rule as part of the NACHA Operating Rules. The rule supports health plans’ and health care providers’ use of the CCD+ for electronic healthcare claims payments, and the electronic “reassociation” of these payments with electronic remittance advices (ERAs).

As the authoring entity for the operating rules governing the ACH Network and standards development organization (SDO) for the CCD+, guidance on industry implementation of the CCD+ should be sought from NACHA. Questions can be sent to Priscilla Holland, Senior Director, at pholland@nacha.org. Information on the new health care EFT and ERA standards, and other health care payments news is also available on NACHA’s Healthcare Payments Resource Site at http://healthcare.nacha.org.

Section 4.1, Receipt of the CORE-required Minimum CCD+ Data Required for Reassociation, of the CAQH CORE 370 Rule requires health plans to “proactively inform the healthcare provider during EFT (Healthcare EFT Standards) and ERA (X12 v5010 835) enrollment that it will need to contact its financial institution to arrange for the delivery of the CORE-required Minimum CCD+ Data Elements necessary for successful reassociation of the EFT payment with the ERA remittance advice…” The CAQH CORE Rule does not specify a method that health plans must use to inform providers to contact their financial institutions; the method used can be determined by each entity.

One potential method is to include a notification in the instructions for completing the EFT enrollment form. The CAQH CORE 380: EFT Enrollment Data Rule requires health plans to “develop and make available to the healthcare provider (or its agent) specific written instructions and guidance for the healthcare provider (or its agent) when completing and submitting the enrollment form.” Health plans may choose to use these instructions to inform providers to contact their financial institutions.

Additionally, CAQH CORE has developed a Sample Provider EFT Reassociation Data Request Letter which contains instructions and a letter template that a provider receiving EFT payments may customize and email to its banks or use as talking points for a phone or in person meeting with its bank contacts to request delivery of the CORE-required Minimum CCD+ Data Elements  (i.e. the ACH Payment Related Information) via a secure, electronic means. Health plans may share this sample letter with providers to assist them with contacting their financial institutions.

No. Per Section 3.4, When the Rule Applies, of the CAQH CORE 370 Rule, “This rule applies when an entity uses, conducts, or processes the X12 v5010 835 and the Healthcare EFT Standards.” Healthcare claim payments made via non-HIPAA-mandated EFT transaction standards (e.g., Fedwire) are out of scope for the CAQH CORE 370 Rule.

Section 4.2.2 of the CAQH CORE 370 Rule requires that health plans track and audit the elapsed time between sending of the X12 v5010 835 and the CCD+ to ensure the elapsed time requirement is met ninety percent of the time as measured within a calendar month.

The CAQH CORE 370 Rule does not specify the exact data elements to be included in the audit log; this data can be determined by each entity. However, as the CAQH CORE 370 Rule, Section 4.2 specifies that the release date for the X12 v5010 835 must be based on the CCD+ Effective Entry Date, CAQH CORE recommends that the data elements captured in the audit log include both the CCD+ Effective Entry Date and the date on which the X12 v5010 835 was actually released for transmission.

Section 4.2, Elapsed Time between Sending the X12 v5010 835 and the CCD+ Transactions, of the CAQH CORE 370 Rule requires health plans to release the X12 v5010 835:

• “No sooner than three business days based on the time zone of the health plan prior to the CCD+ Effective Entry Date

And

• No later than three business days after the CCD+ Effective Entry Date.”

The elapsed time requirement means that a health plan must not send the corresponding X12 v5010 835 earlier than three business days prior to the CCD+ Effective Entry Date or later than three business days after the CCD+ Effective Entry Date.

The figure below presents a visual representation of the requirement for the timeframe of the release of the X12 v5010 835 with respect to the CCD+ Effective Entry Date.

For the example described above, if the CCD+ Effective Entry Date is Thursday, May 4 (and a valid banking day), assuming the health plan’s business days are Monday through Friday, the timeline would be the following:

• Monday, May 1 would be “three business days” prior to the CCD+ Effective Entry Date.
• Tuesday, May 2 would be “two business days” prior to the CCD+ Effective Entry Date.
• Wednesday, May 3 would be “one business day” prior to the CCD+ Effective Entry Date.
• Friday, May 5 would be “one business day” after the CCD+ Effective Entry Date.
• Monday, May 8 would be “two business days” after the CCD+ Effective Entry Date.
• Tuesday, May 9 would be “three business days” after the CCD+ Effective Entry Date.

Therefore, the health plan could release the X12 v5010 835 as soon as, but not before, Monday, May 1, and as late as, but not after, Tuesday, May 9.

No. The CAQH CORE 370 Rule requirement for health plans to release the X12 v5010 835 “no sooner than three business days based on the time zone of the health plan prior to the CCD+ Effective Entry Date” and “No later than three business days after the CCD+ Effective Entry Date” for transmission to the provider means that a health plan must not send the corresponding X12 v5010 835:

• Earlier than three business days prior to the CCD+ Effective Entry Date
• Or later than three business days after the CCD+ Effective Entry Date.

This requirement does not have to-the-hour specificity; the requirement only specifies the number of “business days”. Business days are defined in Section 6.1, Glossary of Terms and Definitions, of the CAQH CORE 370 Rule.

No. The CAQH CORE 370 Rule does not specify how frequently a health plan must generate a claim payment and corresponding X12 v5010 835. For example a health plan may generate claim payments on a daily, weekly, or monthly cycle.

Note: The CAQH CORE 370 Rule does specify requirements for the elapsed time between release of the X12 v5010 835 and Effective Entry Date specified in the CCD+ (i.e., the date funds are available in the provider’s account). Specifically, Section 4.2, Elapsed Time between Sending the X12 v5010 835 and the CCD+ Transactions, of the CAQH CORE 370 Rule requires health plans to release the X12 v5010 835:

• “No sooner than three business days based on the time zone of the health plan prior to the CCD+ Effective Entry Date

And

• No later than three business days after the CCD+ Effective Entry Date.”

The CAQH CORE EFT & ERA Operating Rules do not address which delimiters should be used in the X12 v5010 835 TRN Segment sent in the CCD+ Record #7. The X12 v5010 835 TR3 allows for the delimiters to be defined by the sender of the transaction. The NACHA Operating Rules require the use of the asterisk (*) as the delimiter between data elements and either the backslash (\) or tilde (~) as the segment terminator.

Please Note: As the Standards Development Organization (SDO) that develops and maintains the X12 v5010 835 standard, guidance on implementation of the X12 v5010 835 TR3 implementation guide, and its underlying standard, should be obtained from ASC X12. Information related to the meaning, use, and interpretation of ASC X12 Standards, Guidelines, and Technical Reports can be obtained from ASC X12 via its online ASC X12 Interpretation Portal. NACHA – The Electronic Payments Association is the SDO that maintains the CCD+ standard format. For questions related to the CCD+, or to NACHA in general, contact Priscilla Holland, Senior Director, at pholland@nacha.org.

No. The CAQH CORE 370 Rule does not prohibit a health plan from including additional information in Record #7, Field #3, Payment Related Information, of the CCD+, understanding that entities ensure the field contains the required X12 v5010 835 TR3 TRN segment information and conforms to the NACHA Operating Rules.

NOTE: The CAQH CORE EFT & ERA Operating Rules do not change the meaning, usage, or definition of the X12 v5010 835 data elements or the NACHA CCD+ data fields.

Use of the X12 v5010 835 TRN Segment data elements is referenced in Table 3.3-1 in Section 3.3, CORE-required Minimum CCD+ Data Elements for Successful Reassociation, of the CAQH CORE 370 Rule. Table 3.3-1 identifies the CORE-required minimum set of CCD+ data elements necessary for successful reassociation of the CCD+ and the X12 v5010 835. The CORE-required Minimum CCD+ Reassociation Data Elements include CCD+ Record #5, Field 9, Effective Entry Date, CCD+ Record #6, Field 6, Amount, and CCD+ Record #7, Field 3, Payment Related Information. CCD+ Record #7, Field 3 corresponds to the X12 v5010 835 TRN Segment.

As identified in the table, the X12 v5010 835 TRN Segment is composed of three required data elements (TRN01-481 Trace Type Code, TRN02-127 Reference Identification, and TRN03-509 Originating Company Identifier) and one situational data element (TRN04-127 Reference Identification). Combined with the X12 v5010 835 data elements from the BPR segment (BPR16 and BPR02), the X12 v5010 835 TRN Segment provides information required for the successful reassociation of the X12 v5010 835 and the CCD+.

Please Note: NACHA – The Electronic Payments Association is the Standards Development Organization (SDO) that develops and maintains the CCD+ standard format. For questions related to the CCD+, or NACHA in general, contact Priscilla Holland, Senior Director, at pholland@nacha.org.

Section 4.2, Elapsed Time between Sending the X12 v5010 835 and the CCD+ Transactions, of the CAQH CORE 370 Rule requires that a health plan must not release the X12 v5010 835 earlier than three business days prior to the CCD+ Effective Entry Date or later than three business days after the CCD+ Effective Entry Date. As part of this elapsed time requirement, the CAQH CORE 370 Rule also requires that “a health plan must ensure that the CCD+ Effective Entry Date is a valid banking day and that the corresponding X12 v5010 835 BPR16 date is the same valid banking day.”

To demonstrate that the elapsed time requirement has been met ninety percent of the time (as measured within a calendar month), Section 4.2.2 requires health plans to track and audit the elapsed time between sending of the X12 v5010 835 and the CCD+. The CAQH CORE 370 Rule does not specify the exact data elements to be included in the audit log. However, CAQH CORE recommends that the captured data elements include the CCD+ Effective Entry Date and the date on which the X12 v5010 835 was actually released for transmission. To demonstrate conformance with the requirement to ensure the CCD+ Effective Entry Date and X12 v5010 835 BPR16 EFT Effective Date are the same valid banking day, a health plan may choose to also include the X12 v5010 835 BPR16 EFT Effective Date in the audit log.

Please note: The CAQH CORE 370 Rule builds on the NACHA CCD+ standard format. In addition to compliance with the CAQH CORE 370 Rule requirements, health plans must also comply with the NACHA Operating Rules. Health plans should ensure that the Effective Entry Date included in the CCD+ complies with the NACHA requirements. For questions related to use of the CCD+ or NACHA in general, contact Priscilla Holland, Senior Director, at pholland@nacha.org or 703-561-3916.

Section 4.2, Elapsed Time between Sending the X12 v5010 835 and the CCD+ Transactions, of the CAQH CORE 370 Rule requires that “a health plan must ensure that the CCD+ Effective Entry Date is a valid banking day and that the corresponding X12 v5010 835 BPR16 date is the same valid banking day.” However, the CAQH CORE 370 Rule does not place further requirements around confirming the transfer of funds from the health plan’s financial institution to provider’s financial institution.

Section 4.2.2, Elapsed Time Auditing Requirements, requires the health plan to have the capability to track and audit the elapsed time between sending of the X12 v5010 835 and the CCD+ to ensure the elapsed time requirement is met ninety percent of the time, as measured within a calendar month. The CAQH CORE 370 Rule does not specify the exact data elements to be included in the audit log. However, CAQH CORE recommends that the captured data elements include the CCD+ Effective Entry Date and the date on which the X12 v5010 835 was actually released for transmission.

Section 4.2, Elapsed Time between Sending the X12 v5010 835 and the CCD+ Transactions, of the CAQH CORE 370 Rule requires that a health plan must not release the X12 v5010 835 earlier than three business days prior to the CCD+ Effective Entry Date or later than three business days after the CCD+ Effective Entry Date. Section 4.2.2, Elapsed Time Auditing Requirements, of the CAQH CORE 370 Rule requires that health plans track and audit the elapsed time between sending of the X12 v5010 835 and the CCD+ to ensure the elapsed time requirement is met ninety percent of the time, as measured within a calendar month.

In some cases, health plans (or other HIPAA covered entities) may outsource some or all of their covered functions to a non-covered business associate. It is the responsibility of the HIPAA covered entity to ensure that their business associate(s) supports the HIPAA covered entity in being compliant. Therefore, whether the health plan releases the X12 v5010 835 directly to the provider or outsources that function to a business associate such as a vendor or clearinghouse, the X12 v5010 835 must be made available to the provider no sooner than three business days prior to, and no later than three business days after, the corresponding CCD+ Effective Entry Date.

Health plans that outsource delivery of the X12 v5010 835 to a business associate must also ensure that they have the have the capability to track and audit data to ensure that they are properly delivering the X12 v5010 835 to the provider so that the elapsed time requirement is being met at least ninety percent of the time as measured within a calendar month. The tracking and auditing can be done either directly by the health plan or through its business associate.

The CAQH CORE 370 Rule does not specify what information providers must send to their financial institutions to arrange for delivery of the CORE-required Minimum CCD+ Data Elements.

This said, to assist providers with requesting delivery of the CORE-required Minimum CCD+ Data Elements (i.e. the ACH Payment Information), CAQH CORE has developed a Sample Provider EFT Reassociation Data Request Letter which contains instructions and a letter template that a provider receiving EFT payments may customize and email to its banks or use as talking points for a phone or in person meeting with its bank contacts to request delivery of the ACH Payment Related Information via a secure, electronic means. Health plans may share this sample letter with providers to assist them with contacting their financial institutions.

The NACHA Healthcare EFT Standard FAQs also offer guidance for providers on working with their financial institutions to arrange for delivery of the CORE-required Minimum CCD+ Data Elements. This guidance includes direction regarding the specific information that providers should request, i.e., the “ACH Payment Related Information” and the staff members at the financial institution that providers should contact. The NACHA Operating Rules require all financial institutions to deliver the CORE-required Minimum CCD+ Data Elements upon request. Additionally, as of September 20, 2013, all financial institutions must be able to deliver the CORE-required Minimum CCD+ Data Elements to providers through a secure electronic delivery method.

Please Note: NACHA – The Electronic Payments Association is the authoring entity for the NACHA Operating Rules which govern the ACH Network and the standards development organization (SDO) that maintains the CCD+ standard format. For questions related to the CCD+, or to NACHA in general, contact Priscilla Holland, Senior Director, at pholland@nacha.org. Information on the new health care EFT and ERA standards, and other health care payments news is also available on NACHA‘s Healthcare Payments Resource Site at http://healthcare.nacha.org.

Section 4.2, Elapsed Time between Sending the v5010 X12 835 and the CCD+ Transactions, of the CAQH CORE 370 Rule specifies that “a health plan must release for transmission to the healthcare provider the v5010 X12 835 corresponding to the Healthcare EFT Standards:

• “No sooner than three business days based on the time zone of the health plan prior to the CCD+ Effective Entry Date

And

• No later than three business days after the CCD+ Effective Entry Date.”

Releasing the X12 v5010 835 for transmission is defined as making the X12 v5010 835 available for pick-up by the provider.

No. The CAQH CORE 370 Rule does not require the pick-up of the X12 v5010 835 to occur within the specified maximum timeframe for release of the X12 v5010 835.

Section 4.2, Elapsed Time between Sending the X12 v5010 835 and the CCD+ Transactions, of the CAQH CORE 370 Rule requires that a health plan must not release the X12 v5010 835 (i.e., make the file initially available for pick-up) earlier than three business days prior to the CCD+ Effective Entry Date or later than three business days after the CCD+ Effective Entry Date.

As shown in the figure above, the CAQH CORE 370 Rule timeframe requirement is specific to when the X12 v5010 835 will initially be made available for pick-up. Based on the CAQH CORE 370 Rule elapsed time requirements, the X12 v5010 835 transaction will not be initially available for pick-up earlier than three days prior to the CCD+ Effective Entry Date and no later than three days after the CCD+ Effective Entry Date, based on the time zone of the health plan.

However, the CAQH CORE Rule timeframe requirement does not require that the pick-up of the available X12 v5010 835 transaction occur during this timeframe. A provider (or other entity acting as the receiver) may pick-up the X12 v5010 835 any time after it has been made available by the health plan.

Additionally, while the CAQH CORE 370 Rule places timing requirements around when the X12 v5010 835 will initially be made available, the CAQH CORE 370 Rule does not constrain the ongoing availability of the X12 v5010 835 after it has been released by the health plan, in conformance with the maximum elapsed time requirements. It is a health plan’s individual business decision to specify how long the X12 v5010 835 will be available for pick-up after it has been released by the health plan.

Use of the ASC X12N v5010 835 BPR Segment data elements is referenced in the following sections of the CAQH CORE 370: EFT & ERA Reassociation (CCD+/835) Rule:

• Table 3.3-1 in Section 3.3, CORE-required Minimum CCD+ Data Elements for Successful Reassociation, identifies the CORE-required minimum set of CCD+ data elements necessary for successful reassociation of the CCD+ and the X12 v5010 835. The CORE-required Minimum CCD+ Reassociation Data Elements include CCD+ Record #5, Field 9, Effective Entry Date, CCD+ Record #6, Field 6, Amount, and CCD+ Record #7, Field 3, Payment Related Information. CCD+ Records #5 and #6 correspond to BPR16 Date (EFT Effective Date) and BPR02 Monetary Amount (Total Actual Provider Payment Amount) respectively in the ASC X12N v5010 835. BPR16 and BPR02 provide information required for the successful reassociation of the ASC X12N v5010 835 and the CCD+.
• Section 4.2, Elapsed Time between Sending the X12 v5010 835 and the CCD+ Transaction, specifies requirements for health plans to ensure that the CCD+ Effective Entry Date is a valid banking day and that the corresponding ASC X12N v5010 835 BPR16 (EFT Effective Date) is the same valid banking day.

Beyond these references in the CAQH CORE 370 Rule, the CAQH CORE EFT & ERA Operating Rules do not address the ASC X12N v5010 835 BPR Segment.

Please Note: While the CAQH CORE EFT & ERA Operating Rules build upon and support use of the ASC X12N v5010 835 transaction, the rules do not change the meaning, usage, or definition of the ASC X12N v5010 835 data elements. As the Standards Development Organization (SDO) that develops and maintains the ASC X12N v5010 835 standard, guidance on understanding the use of the ASC X12N v5010 835 TR3, and its underlying standard, should be obtained from ASC X12. Information related to the meaning, use, and interpretation of ASC X12 Standards, Guidelines, and Technical Reports can be obtained from ASC X12 via its online ASC X12 Interpretation Portal.